Name of Provider (Last Name, First Name):*

Provider Phone Number (xxx) xxx-xxxx: *

Provider Street Address: *

Provider City:*

Provider State:*

Provider Zip Code:*

Licensor (Last Name, First Name):*

License #:

Minnesota Child Care Licensing Rule 9502 requires immediate reporting of the following injuries/incidents. (Please check all those pertaining to your report):

Animal bites (9502.0435, subpart 12G) Injury of a child during child care hours which requires the attention of a medical professional either during or after child care hours (parent should be informed as soon as possible - 9502.0375, subpart 2D) Death of a child in care (9502.0375, subpart D)

Fire in child care home which requires service of fire department (within 48 hours of incident - 9502.0375, subpart C) Any suspected case of reportable disease as listed in Scott County Child Care Provider Policy (9502.0435, subpart 16E)

CAREGIVER SHALL REPORT IMMEDIATELY TO THE POLICE OR SOCIAL SERVICES INTAKE UNIT (952-445-7751) ANY SUSPECTED CASE OF PHYSICAL ABUSE, SEXUAL ABUSE, OR NEGLECT OF A CHILD; OR ANY SUSPICIONS OF SUCH ACTIONS RESULTING IN DEATH OF A CHILD. (9502.0375, SUBPARTS 1 AND 2B)

Name of Child (Last Name, First Name):*

Child's Date of Birth: (MM/DD/YYYY)*

Parent 1 Name (Last Name, First Name):*

Telephone:

Cell Home Work Other

Number (xxx) xxx-xxxx:*

Telephone:

Cell Home Work Other

Number (xxx) xxx-xxxx:

Parent 2 Name (Last Name, First Name):

Telephone:

Cell Home Work Other

Number (xxx) xxx-xxxx

Telephone:

Cell Home Work Other

Number (xxx) xxx-xxxx:

Date of Injury/Incident (MM/DD/YYYY):*

Time of Injury/Incident (xx:xx a.m./p.m.):*

Location Where Injury/Incident Took Place:*

Describe Injury/Incident:*

Action Taken By Provider:*

Action Taken By Parent:*

Child Care Provider's Signature (Type Name):*

REMINDER: Print a copy of the report for your file.